Eating Disorders at Middle Age, Part 1

Until recently, the problem of eating disorders among middle-aged women was largely overlooked in psychiatry and medicine. The definition of middle life is somewhat arbitrary and in current flux, due in part to the increased longevity of people in the U.S. and Western Europe. This article focuses on increasing the knowledge of eating disorders in this population, which we define as the period of life between 35 and 65 years of age.

Individuals may develop an eating disorder for the first time at middle life, but to date most patients described in the literature have had the problem for at least 10 years. While the manifest problem may be understood as a pathologic means of coping with changes in body image due to aging, the clinical course and motivation behind this maladaptive mechanism lead to different clinical presentations.

We want to increase awareness of this neglected clinical problem, to offer some recommendations for treatment, and to encourage others to augment the knowledge base by describing how eating disorders in middle life are both similar to and different from eating problems at other periods in the life cycle.

Introduction

Despite the overall increased awareness of the negative effects of being overweight, as well as a greater than $15 billion diet industry, Americans are getting larger more quickly than the rest of the world. Nations like France, where people consume a diet rich in fatty foods such as cheese, cream and whole milk, manage to maintain an obesity rate of slightly over 6%. Americans, despite many “low-fat” and “no-fat” foods, maintain an average national obesity rate of over 40%. Current data argue that this disparity is related to larger portion sizes, higher stress levels, and lower levels of regular exercise, not to food itself. Our attitudes towards food govern the way in which we consume food and help explain why we eat so much. Likewise, a combination of physical, interpersonal, and cultural factors determine our body image at any given point in the life cycle. Americans measure self-worth by appearance and make pejorative comments about their bodies despite objective measures to the contrary. How we will use or abuse food as we age is only one factor in how we alter that image to sustain a sense of self or of self-esteem.

According to a 1997 Psychology Today poll, which is the largest study on body image and eating disorders to date (involving more than 3,400 women and 500 men between 13-90 years of age), gaining weight is at the top of the list for negative influences on body image in both men and women.1 This was true even though most were of normal weight. Two-thirds of the women and a third of the men said that gaining weight produced the greatest detriment to their self-image. Nearly half of the women polled reported being preoccupied with weight and finding displeasure with their weight regardless of age. In contrast, the poll found that men of all ages were much less dissatisfied with their appearance. Those from 30-39 and 50-59 years old were most dissatisfied. Another large-scale survey, which included women up to age 75, found that more than 70% of women aged 30-74 were dissatisfied with their weight even though they were of normal weight.2 As women age, body dissatisfaction increases.

Biological Bedrocks

Physiologic aging has various effects on the human body that also alter body image, particularly in women. Until age 60, women tend to gain 5-10 lb per decade of life. Body shape changes, skin loses its elasticity (i.e., crows’ feet), and hair turns grey and thins. These normal lifecycle changes are likely to be particularly problematic for women because body fat deposition tends to increase with each developmental milestone, for example, puberty, pregnancy, and menopause.3

Body image can also be threatened by any medical problem, chronic illness, restriction in social activity, and change in relationships with family and friends (i.e., divorce, or becoming a grandparent). This gender-based finding likely contributes to the “normative discontent” women feel about their bodies, and may contribute to the initiation and/or maintenance of eating disorders and exercise addiction in middle life.4

In clinical practice, we educate women that these biological facts about midlife transition are likely genetically based because females are: (1) born with more fat cells than males; (2) have slower metabolic rates than males; and (3) have different hormonal influences than males (i.e. estrogen, progesterone), which increase the likelihood of weight gain throughout the life cycle. Women may also feel worse about their bodies with age because of lowered energy levels and other sensory and motor changes.

While all body systems change with age, it appears that women worry most about their weight and skin. For example, skin changes can be the most devastating for women because they are the most visible and also are the target of increasing media pressure for change. Women are bombarded with suggestions about defying their age and urged to “lie about [their] age,” leaving them with the impression that aging is bad and that they should not be satisfied with themselves when they see “crows’ feet” or other signs of aging developing. The overall message is that aging is bad and wrinkles are worse, and that the only solution is to use products, reconstructive surgery, or virtually anything in order to achieve a younger, more ideal look.

Herein lies the difficult assessment that women must make about themselves in order to age successfully: Do they accept society’s message that younger is better and strive for unattainable or unnatural ideals, or allow themselves to become internally self-worthy and maintain a positive body image despite some noticeable and possibly inevitable physiological shifts?

The Scope of the Problem

Body image derives from conscious and unconscious processes, a manifestation of internal and external promptings that have been shaped over the years by life experience, media images, and feedback from other people. Separating out the potential developmental antecedents of the body image disturbance that has led to and helped nurture the eating disorder allows the patient to better understand herself, her life, and the struggles that have shaped her into who she is today.

As a whole, 89% of the women polled by Psychology Today wanted to lose weight. The average woman is 5’5″ tall and weighs 140 lb, but would like to weigh 125 lb, a desire that 15% of women said would be worth sacrificing more than five years of their lives to achieve. Another 24% of the women surveyed would sacrifice three years of their lives to achieve their desired weight.1

It is no surprise that preoccupation with body image affects a woman’s sense of herself. For over 56% of women in our society, being a woman entails preoccupation and dissatisfaction with her overall appearance and body size. This desire to diet runs deeper than just a willingness to restrict calories and to exercise. Instead, it goes far beyond, to a pathological “I’ll do anything” mindset to lose weight. This mentality is most commonly associated with women in their adolescent or young adult years. Thus, it is not surprising that 62% of females 13-19 years old are dissatisfied with their weight. What has been neglected and unrecognized is the larger percentage of older women who are dissatisfied with their body weight. This dissatisfaction with body weight rises to 67% in females over the age of 30.1 Today’s young women are being initiated to feelings of body dissatisfaction at a young age; these attitudes about their bodies stay with them and later prevent a normal transition into middle life.

Because middle-life is usually viewed as that time when men and women have achieved identity and a personal sense of power, one begins to wonder why a focus on body image is so pervasive in this age group. Body dissatisfaction is not only higher than in past years, it has been accelerating—from 25% in 1972 to 38% in 1985 to 56% in 1997.1

Diets leave women unsatisfied with the results. In 2001, over 93% of liposuction patients were women between the ages of 17 and 74 years old, but 98.7% were within 50 lb of their ideal chart weight. While the procedures have been improved and significant medical complications (e.g. bleeding, pulmonary emboli) have decreased, the success of liposuction does not address the increasingly negative body image of millions of women who believe that weight reduction or body fat removal will make them happier and healthier human beings. It seems as though the alternative of liposuction only addresses part of the problem, namely the female desire to come closer to the slender ideal, while it fails to resolve the negative body image that fuels the self-defeating dieting that often precedes and follows such procedures. Consideration of these facts makes clinicians wonder if women who seek plastic surgery at middle life should be screened for an eating disorder.

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